Making Seconday Care a Primary Concern: the Rural Hospital in Ecuador

Below is an exert from the Pan American Health Organization’s article by Andean Health and Development’s founder, David Gaus, M.D.

In 2001, Andean Health & Development (AHD, Milwaukee, Wisconsin), also known as Salud y Desarrollo Andino (Saludesa, Quito, Pichincha, Ecuador), a non-governmental organization (NGO), opened a 17-bed rural hospital, built jointly with the local municipality and the Ministry of Health (MOH) of Ecuador. The hospital serves a rural community of 50 000 that had no prior secondary care services. AHD/Saludesa’s efforts to develop a quality, primary/secondary care, selfsustaining public/private health network have led to important experiences in the administration of a rural hospital. In this article, AHD shares some of
these experiences through a discussion of rural hospitals in Ecuador.

Rural communities in Ecuador continue to experience unprecedented urban and international migration (1), resulting in shrinking rural infrastructures as political forces increasingly respond to the demands of growing urban populations. Ecuador’s public spending on health is 2.1% of its national budget, among the lowest in the Western Hemisphere (2). Furthermore, the high turnover rate among top-level MOH personnel—31 ministers in 37 years (3)—has made it exceedingly difficult for Ecuador to implement a long-term strategic health plan or define the role of the MOH in the health care landscape.

The MOH, Social Security Institute (Instituto Ecuatoriano de Seguridad Social, IESS), private sector physicians, and NGOs form a network of more than 4,000 primary care centers throughout the country (4). However, the secondary and tertiary care facilities, available in the larger urban areas, have extremely limited access for rural populations. Poor, rural patients requiring transfer for secondary or tertiary care encounter almost insurmountable obstacles.

A three-hour transfer to the capital city for a high-risk patient in labor can turn into nine hours when there is no receiving facility. In a situation such as this, the birth may occur en route, in the back of a pickup truck. Common obstacles to transporting patients to urban hospitals are:
• Patient unfamiliarity with large cities and their transportation systems
• Costly transportation for transfer
• Lack of in-town family support and lodging for family members of ill patients
• Bed unavailability due to severely congested tertiary care hospitals
• Insensitive medical personnel at receiving urban hospitals

Despite the obstacles however, technically, administratively, and financially well-maintained RSCHs, situated in appropriately-sized communities, offer many advantages over their urban tertiary counterparts. Specifically, the well-run RSCH:
• Keeps patients close to families
• Prevents traumatic long distance journeys
• Provides continuing medical education to an oftentimes relatively abandoned group of primary care providers in the community
• Decongests overburdened tertiary care city hospitals
• Delivers important curative services more economically due to lower fixed overhead costs
• Provides important leadership in developing local
capacity in the public and private health sector

For the complete PAHO Article, please click here:

Rev Panam Salud Publica/Pan Am J Public Health 23(3), 2008 217
Gaus et al. • Making secondary care a primary concern

By David Gaus, Diego Herrera, Michael Heisler, Barnett L. Cline, and Julius Richmond, University of Wisconsin, School of Medicine and Public Health,
Madison, Wisconsin, United States of America and Andean Health & Development, Emory University School of Medicine, Atlanta, GA, Department of Tropical Medicine, Tulane University, New Orleans, LO, Harvard Medical School, Boston, MA, Former U.S. Surgeon General, Former U.S. Assistant Secretary of Health.

Please click HERE to continue reading.

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